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2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS
Vol. 2 No. 2:4 doi: 10.3823/713

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Emergence of Klebsiella pneumoniae Carbapenemase (blaKPC-2) in members of the Enterobacteriaceae family in Palestine

Randa Kattan1,3, Rawan Liddawi1,3, Raed Ghneim1,3, Issa Siryani1,3, Rula Al-Dawodi1,3, Afaf Abu-Diab1, Riyad Ghneim1, Madeleine Zoughbi1,3, Abed-El-Razeq Issa1,3, Randa Al Qass1,3, Sultan Turkuman1, Lucia Corradin1, Hiyam Marzouqa1, and Musa Hindiyeh1,2,3
1 Caritas Baby Hospital, Bethlehem, Palestine; 2 Bethlehem University, Bethlehem, Palestine; 3 Palestinian Forum for Medical Research (PFMR), Ramallah, Palestine. Correspondence:

 hindiyeh@yahoo.com
* Musa Y Hindiyeh, PhD, D (ABMM); MT, (ASCP) Caritas Baby Hospital Bethlehem Palestine

Abstract
Background: The global spread of carbapenem resistant Enterobacteriaceae
(CRE) has limited the physicians’ antimicrobial treatment options of infected patients. CREs’ which carry the Klebsiella pneumonia Carbapenemase (blaKPC) resistance mechanism have been rapidly spreading in many parts of the world, and have been responsible for high patients’ morbidity and mortality.

Methods: Two protocols recommended by the Centers for Disease Control and
Prevention (CDC) were followed to detect CREs’ in Palestine. In addition, the antimicrobial sensitivity patterns for several antibiotic classes were determined for the isolated CREs’ by the disc diffusion method according to the clinical and laboratory standard institute (CLSI) M100-S22 guidelines. The Minimal Inhibitory Concentrations (MICs) of the carbapenem, ertapenem, imipenem and meropenem were determined for all the CREs’ by E-test. The isolates β-lactam resistance mechanisms were further investigated by analyzing 31 different types of β–lactamase genes by polymerase chain reaction (PCR).

Results: Four bacterial isolates, three Enterobacter cloacae and one Klebsiella
pneumoniae, were determined to be non-susceptible to one or all of the carbapenems (ertapenem, imipenem and meropenem) tested. All isolates which carried the blaKPC-2 gene showed an extreme drug resistance profile. These isolates were resistant to all β-lactam antibiotics, co-trimoxazole and gentamicin, while susceptible to only amikacin and colistin sulfate. Different combination of plasmid encoded β–lactamase genes (blaTEM, blaSHV, blaOXA-1, blaMIR-1, blaGES-23 and blaKPC-2) were present in these isolates. Of interest, was the isolation of the first E. cloacae strains co-producing the blaKPC-2 and a novel blaGES-23 β-lactamase.

Conclusions: The presence of all these plasmid encoded β-lactamase in Palestine
is alarming and mandates actions to be taken to control antibiotics usage and the activation of hospital infection control programs in order to prevent the spread of these extremely drug resistant bacteria.

Running title: Emergence of blaKPC-2 positive Enterobacteriaceae family members
in Palestine

This article is available from: www.iajaa.org

Key words: blaKPC, blaGES, Carbapenemase, Palestine

© Under License of Creative Commons Attribution 3.0 License

1

screening agar plates have been developed and utilized for the rapid detection of blaKPC resistant bacteria. Chromogenic agar. Antimicrobial susceptibility testing and β-lactamase antimicrobial resistance gene families were also investigated. Canada. In this study.3823/713 Our Site: http://www. one of the disadvantages of these assays was the need for specialized equipment and well trained personnel. the utilization of the carbapenem. Interestingly. bacterial isolates carrying this resistance mechanism have rapidly disseminated worldwide (1. All swabs were transported to the clinical laboratory within 30 minutes for analysis. France. multi-drug resistant Acinetobacter baumannii and carbapenem resistant Enterobacteriaceae (CRE). rectal. ertapenem.0 License 2 .iMedPub Journals 2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. has been shown to consistently identify blaKPC resistance mechanism. Carbapenems are usually the last class of antibiotics used to treat infections caused by resistant bacteria such as the ones carrying the Extended Spectrum β-Lactamases (ESBLs’). blaKPC. was first reported in a K. As a result of the increase in the dissemination of Methicillin-resistant Staphylococcus aureus (MRSA). Switzerland. Nevertheless. within the Enterobacteriaceae family. pneumoniae isolate detected in a patient residing in the United States of America (USA) in the year 2001 (2). Materials and Methods Patient surveillance samples Caritas Baby Hospital (CBH) is an 89 bed pediatric hospital located in the district of Bethlehem. More recently. China. The resistance mechanism. we report the emergence and characterization of blaKPC positive bacteria in Palestine. this agar base medium still missed certain strains of blaKPC positive Enterobacteracae (1. reports about the isolation of blaKPC prodcuing members of the Enterobacteriaceae family in the Arabic speaking Middle Eastern countries were scarce. Consequently. automated systems have been reported to miss the detection of blaKPC resistance mechanism in 7% to 87% of the blaKPC positive K. Vancomycin Resistant Enterococcus (VRE). 12). Since then. blaSME. These countries include the eastern part of the USA. This in part could be due to the presence of the blaKPC genes on plasmids with varying sizes and structures (3). However. blaIMI. ensuring that all sides of the swab touched © Under License of Creative Commons Attribution 3. fluoroquinolones and the aminoglycosides. several countries became “Hot Spots” for such bacterial drug resistance mechanism.imedpub. CBH infection control unit mandates that all patients referred to CBH from other medical institutions should undergo surveillance for drug resistant bacteria. Not only that. Colombia. 2 No. 4. Israel. 22). Since 2008. On the other hand. Palestine. blaGES and blaKPC). Reports from varying parts of the world have shown that bacteria carrying the blaKPC gene are usually non-susceptible to co-trimoxazole. Brazil and Italy (4-13). Greece and the eastern part of China (1). Detection of carbapenem resistant Enterobacteriaceae Two different protocols were utilized to detect CREs’ as reported by the American Centers for Disease Control and Prevention (CDC) (23). Bacterial isolates carrying the blaKPC resistance mechanism have been reported in several countries such as the USA. Klebsiella pneumoniae carbapenemase (blaKPC) has been the only resistance mechanism to rapidly disseminate in many parts of the world. Indeed. nose and umbilical swabs (N = 5. Greece. respectively (16). However. have complicated the detection of the blaKPC resistance mechanism in the clinical laboratory (14. CA) by the nursing staff members from all patients upon admission to the hospital sections. not all ertapenem resistance is due to blaKPC (17).928) were collected on Copan Amies sterile transport swabs (Copan Diagnostics. United Kingdom). the Drigalski agar-based culture medium was reported to have excellent sensitivity and specificity for the detection of bacteria carrying the blaKPC resistance mechanism (1). France). Corona. 2). while the majority of the isolates are susceptible to tigecycline and colistin sulfate (1. pneumoniae (15). The variation in susceptibility patterns and the heterogeneous expression of the β-lactamases. 15). 2:4 doi: 10. but the utilization of the imipenem and meropenem antibiotics in the disk diffusion assays has also been shown to misidentify carbapenem resistance due to blaKPC in 29% and 52% of the cases. Indeed.com/ Introduction The emergence of carbapenem resistant Enterobacteriaceae (CRE) has complicated the management of infected or colonized patients (1). Protocol one: surveillance swabs received by the laboratory personnel were inoculated on MacConkey agar plates (Oxoid. Israel. has been evaluated for the detection of blaKPC positive bacteria. The inconsistency in the performance of standardized classical microbiology assays has led to the utilization of molecular assays for the rapid detection and identification of the carbapenem resistant bacteria. which are mainly encoded on plasmids. in particular the blaKPC resistance mechanism. Several highly sensitive Polymerase Chain Reaction (PCR) assays and Real-Time PCR assays have been developed and validated for the rapid detection and identification of blaKPC positive bacteria (18-21). Since the description of the class A serine β-lactamases (blaNMC. CHROMagarTM KPC (CHROMagar.

inoculated MacConkey agar plates were evaluated for the presence of colonies within the inhibition zone of the meropenem and ertapenem disks. blaNMC-A. United Kingdom). The modified Hodge Test confirmed the presence of the carbapenemase enzyme as all four isolates produced a clear clover leaf-type indentation (Figure 1). co-trimoxazole (23. blaSME.75/1.com/ the initial quadrant. United Kingdom) after a 10µg meropenem disk was placed into the broth using a sterile forceps. blaDHA-1 and -2). Bacterial identification and antimicrobial susceptibility testing All bacterial isolates suspected of being CREs’ were identified by the API-20E (bioMerieux. Briefly. The obtained nucleotide sequences were compared with previously described blaKPC and blaGES sequences obtained from the GenBank database (http:// www. USA) after staining with ethidium bromide.asp). colistin sulfate (10 µg) (Oxoid.. pneumoniae had prior hospitalization in a Palestinian medical institution. blaACC-1. Protocol two: the same surveillance swabs used in protocol one were inoculated in 5ml trypticase soy broth (TSB) (Oxoid. 27). blaMIR-1. ciprofloxacin (5µg). 26.org/Studies/other.iMedPub Journals 2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. norfloxacin (10µg).imedpub. Inc. imipenem (10µg). of which. blaFOX-1 to 5. enem resistance molecular classes (class A: blaKPC. blaVIM. PCR amplification was performed in MJP-100 Thermocycler using the recommended amplification conditions (18. Well isolated colonies were used to prepare 2. tigecycline (15µg). chloramphenicol (30µg). After overnight incubation at 37oC. blaCTX-M-2 and -5. After overnight incubation at 37oC. Rehovot) and incubated at 35oC for 18-24 hours. carbapenems resistance was confirmed by determining the Minimal Inhibitory Concentration (MIC) of ertapenem. and a meropenem (10μg) and an ertapenem (10μg) disks were placed in this area using sterile forceps.1 Sequencing Standard Kit (Life Technologies. blaSHV. blaOXA-5 and -10. cefotaxime (30µg). nitrofurantoin (300µg). All bacterial colonies were identified and sensitivity testing was performed as described below (24. 100ml aliquot was heated at 100oC for 15 minutes to prepare the bacterial cell lysates that were used for the PCR analysis. in addition to the different carbap© Under License of Creative Commons Attribution 3. The amplified PCR products were visualized on 1. The initial quadrant was plated as a lawn. blaGES.0 License 3 . blaLAT. suspected bacterial isolates were streaked for isolation on 5% Sheep Blood agar (SBA) (Hy-labs. blaSPM. class B: blaNDM. blaOXA-1. 26).and blaAmpC (blaACT-1. cloacae strains were isolated from a patient with prior hospitalization in an Israeli medical institution while the patient with the K. blaGIM.lahey. Extended Spectrum β-Lactamase (ESBL) [blaTEM. imipenem and meropenem using the Etest® (bioMe´rieux Inc. ceftazidime/clavulanate (30/10 µg). ceftriaxone (30 µg). blaOXA-55. amoxycillin/clavulanate (20/10µg ). Results Detection of carbapenem resistant Enterobacteriaceae (CRE) Four different bacterial strains (3 Enterobacter cloacae and 1 Klebsiella pneumoniae) were isolated from the rectal swabs of 2 patients upon referral to CBH from local and regional medical institutions (Table 1). cefoxitin (30µg). the primers used to determine the type of the amplified blaGES gene were: forward 5’-atgcgcttcattcacgcac-‘3 and reverse 5’-ctatttgtccgtgctcagga -‘3. blaCTXM. gentamicin (10µg). cefotaxime/ clavulanate (30/10 µg). imipenem and meropenem) were further evaluated by the modified Hodge test (25). piperacillin/tazobactam (100/10 µg). blaSIM. 2 No.0 (Gene Code Corporation. blaPER-1 and -2]. France) according to the manufacturer’s instructions. blaOXA-2 and -20. Susceptibility patterns were determined for amikacin (30µg). aztreonam (30µg). blaIMP. All bacterial isolates that exhibited an intermediate or resistant profile to any of the carbapenems tested (ertapenem. UK). USA) and analyzed using the Sequencher 5. blaOXA-48. USA). ertapenem (10µg). blaCMY. 2:4 doi: 10. blaOXA-50) were performed as previously reported (18. Polymerase Chain Reaction (PCR) Amplification of Different β-Lactamase Genes Analysis of the β-lactamase gene groups. ofloxacin (5µg). Sequence analysis was performed on the Applied Biosystems 3130 Genetic Analyzer (Life Technologies. blaOXA-60. Susceptibility testing was performed by disk diffusion method on Mueller Hinton agar as recommended by the Clinical and Laboratory Standard Institute guidelines (CLSI) (25).) on Mueller-Hinton plates (Oxoid. The primers used to determine the type of the amplified blaKPC PCR product were: forward 5’-atgtcactgtatcgccgtct-‘3 and reverse 5’-ttttcagagccttactgccc-‘3. cefepime (30µg). The 3 E.0% agarose gel (Life Technologies. 25). ceftazidime (30µg). In addition. All isolates were detected by both protocols used to isolate CRE. Germany) and sequenced using the BigDye® Terminator V1.3823/713 Our Site: http://www. meropenem (10µg). the inoculated tube was vortexed for 15 seconds and a 100µl aliquot was streaked on MacConkey agar plate and incubated overnight at 37oC in ambient air. In addition. USA). Determining blaKPC and blaGES types by sequence analysis Amplified PCR products of the expected size for blaKPC (882bp) and blaGES (864bp) were purified using HighPure PCR product Purification Kit (Roche. class D: blaOXA-69.75 µg). cefpodoxime (10µg).0 MacFarland standard in sterile saline.

coli (ESBL). 2 No. Complete sensitivity patterns were noted only for amikacin and colistin sulfate. Non-susceptible antibiotic profile was noted to all of the β–lactam antibiotics. the blaMIR-1 gene was detected in the 3 E.0 License 4 . all isolates carried the blaTEM and blaSHV genes. the three E. three of the isolates (2 E. All four blaKPC positive isolates produced the characteristic cloverleaf-like indentation. coli (ESBL producer) as a negative control. Sequence analysis of the blaKPC (760 base pair) and blaGES (823 base pairs) PCR products revealed that all 4 bacterial isolates carried the blaKPC-2 gene while the 3 E. cloacae while it was absent in the K. In addition. Description of the carbapenemase positive bacterial isolates. E. pneumoniae) carried the blaOXA-1 gene (Table 3).iMedPub Journals 2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. imipenem and meropenem) by Etest®. Similarly. a variable sensitivity pattern was noted for the bacteriostatic antibiotic tigecycline. PCR amplification of β-lactamase genes and sequence analysis of blaKPC and blaGES PCR products PCR amplification of 31 different β-lactamase genes representing members of the ESBL’s. pneumoniae isolate (Table 3). As for the blaAmpC β-lactamases.imedpub. All isolates had a non-susceptible antibiotic profile for ciprofloxacin. All 3 blaGES-23 sequences were deposited in the Genbank under the accession numbers JX437086-88. 1A3 and 1A4) and an E. while the negative control. cloacae isolates co-produced a novel type of the blaGES called blaGES-23 gene. cloacae K.3823/713 Our Site: http://www.com/ Table 1. Determination of the MIC of the carbapenems (ertapenem. 1A2. Bacterial Isolate E. while depending on the isolate. cloacae E. Variable sensi- Discussion The emergence of carbapenem resistant Enterobacteriaceae (CRE) has exerted an unprecedented pressure on the health © Under License of Creative Commons Attribution 3. confirmed the resistance profile to the carbapenems. a susceptible and nonsusceptible profile was noted for norfloxacin and ofloxacin (Table 2). Figure 1: Modified Hodge Test of the four blaKPC positive isolates (1A1. pneumoniae Isolate Number 1A1 1A2 1A3 1A4 Sample Collection Site Rectal Rectal Rectal Rectal Patient Sex / Age F/ 2 months F/ 2 months F/ 2 months F/ 6 months Date of Detection February 2008 February 2008 February 2008 March 2012 Referral Hospital Israeli Israeli Israeli Palestinian Patients Residency Hebron Hebron Hebron Ramallah tivity patterns were observed for the fluoroquinolones. cloacae and 1 K. Antimicrobial susceptibility patterns Antimicrobial susceptibility testing of the CRE isolates for 24 different antibiotics revealed a multi-drug resistant profile (Table 2). With regard to the ESBL genes. All isolates had carbapenems MIC’s greater than 32 µg/ml (Table 2). and the carbapenemases revealed that carbapenem resistance in the 4 isolates was due to the presence of the blaKPC carbapenemase (Table 3). positive did not produce the characteristic indentation. AmpC. 2:4 doi: 10. co-trimoxazole and gentamicin. while none carried any of the blaCTX genes. cloacae isolates also co-produced the Guiana extended-spectrum β-lactamases (blaGES) (Table 3). cloacae E. Moreover. cloacae. The blaGES-23 had a point silent mutation at nucleotide position 159 where the nucleotide cytosine was replaced by an adenine in all three E.

3823/713 Our Site: http://www. 5 . while the MIC’s for the carbapenems (ertapenem. 12. cloacae DD / E-Test 1A4 K. However. Of interest was the rapid dissemination of blaKPC resistant bacteria in the Eastern part of the USA. cloacae DD / E-Test 1A3 E. 2:4 doi: 10. cloacae DD / E-Test 1A2 E. imipenem and meropenem) were determined by the E-test. Other countries in the world have reported sporadic isolation of Enterobacteriaceae family members carrying the blaKPC resistance mechanism (1).com/ Table 2. Antimicrobial susceptibility patterns of the different blaKPC positive isolates was determined and interpreted by the disk diffusion (DD) method.iMedPub Journals 2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. China.0 License 17. 10. 1A1 E. The interpretation of the sensitivity patterns were: S = Sensitive. © Under License of Creative Commons Attribution 3. R = Resistant.imedpub. reports about the isolation of blaKPC producing members of the Enterobacteriaceae family in any of the Arabic Middle Eastern countries are infrequent. 2 No. I = Intermediate. 28). This in part was due to the limited antimicrobial options available for treating infected patients and to the recommendations for isolating patients with CRE. Greece and Israel (4.75/1. pneumoniae DD / E-Test Antibiotic (concentration) Amikacin (30µg) Gentamicin (10µg) Amoxycillin / Clavulanate (20/10µg ) Piperacillin / Tazobactam (100/10µg) Aztreonam (30µg) Ceftazidime (30µg) Ceftazidime / Clavulanate (30/10µg) Cefotaxime (30µg) Cefotaxime / Clavulanate (30/10µg) Cefpodoxime (10µg) Ceftriaxone (30µg) Cefepime (30µg) Cefoxitin (30µg) Ofloxacin (5µg) Ciprofloxacin (5µg) Norfloxacin (10µg) Nitrofurantoin (300µg) Chloramphenicol (30µg) Co-trimoxazole (23.75µg) Ertapenem (10µg) Imipenem (10µg) Meropenem (10µg) Tigecycline (15µg) Colistin sulfate (10µg) S R R R R R R R R R R R R I R R S R R R / >32 µg/ml R / >32 µg/ml R / >32 µg/ml I S S R R R R R R R R R R R R I R I S R R R/ >32 µg/ml R/ >32 µg/ml R/ >32 µg/ml I S S R R R R R R R R R R R R S R I S R R R/ >32 µg/ml R/ >32 µg/ml R/ >32 µg/ml I S S R R R R R R R R R R R I S I S I S R R/ >32 µg/ml R/ >32 µg/ml R/ >32 µg/ml S S care provider’s ability to manage infected or colonized patients.

cloacae Positive Positive Negative Negative Positive Negative Negative Negative Negative Positive Negative Negative Negative Negative Positive Negative Negative Positive Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative E. a large number of Palestinians living in occupied Palestine seeks the medical services in the Israeli hospitals. 2:4 doi: 10. cloacae blaTEM blaSHV blaCTX-M-2 and 5 ESBL blaCTX-M blaOXA-1 blaOXA-2 and 20 blaOXA-5 and 10 blaPER-1 and 2 blaACT-1 blaMIR-1 blaAmpC blaCMY and LAT blaFOX-1 and 5 blaDHA-1 and 2 blaACC-1 and 2 blaKPC blaNMC Class A blaSME blaGES blaOXA-69 blaOXA-55 Class D blaOXA-48 blaOXA-50 blaOXA-60 blaIMP-1 blaIMP-2 blaVIM-1 Class B blaVIM-2 blaSPM-1 blaGIM-1 blaSIM-1 blaNDM Positive Positive Negative Negative Negative Negative Negative Negative Negative Positive Negative Negative Negative Negative Positive Negative Negative Positive Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative E. 2 No.iMedPub Journals 2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. cloacae isolated from a patient upon admission to Caritas Baby Hospital right after hospitalization in an Israeli hospital. Palestinians who were hospitalized in Israel and are returning back to the Palestinian hospitals have a high probability of being colonized with blaKPC positive Enterobacteriaceae (10. Since blaKPC positive Enterobacteriaceae has disseminated in the majority of Israeli medical institutions. pneumoniae in a patient © Under License of Creative Commons Attribution 3. this report describes the first isolation of blaKPC positive E. Determination of the presence of several β-lactamase genes in the carbapenem resistant isolates by PCR. pneumoniae Positive Positive Negative Negative Positive Negative Negative Negative Negative Negative Negative Negative Negative Negative Positive Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative 1A2 1A3 1A4 Because of medical tourism.com/ Table 3. 1A1 Group β-lactamase Genes E.imedpub. Indeed. cloacae Positive Positive Negative Negative Positive Negative Negative Negative Negative Positive Negative Negative Negative Negative Positive Negative Negative Positive Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative K. In addition.0 License 6 . what was more alarming was the detection of blaKPC positive K.3823/713 Our Site: http://www. 20).

30-37). Complete susceptible patterns were noted only to amikacin and colistin sulfate. E. to our knowledge. isolated from hospital sewage in Brazil (44). cloacae isolates 1A2. blaKPC-2. pneumoniae isolates positive for the blaKPC gene and with similar drug resistance profile as in occupied Palestine have been previously reported from several Israeli medical institutions and several countries worldwide (1. BlaKPC-2 which has been reported in Israel and in several countries worldwide differ from the widely disseminated blaKPC-3 by only one amino acid difference at position 272. In addition. of which blaKPC-2 and blaKPC-3 are endemic in Israel (26). ciprofloxacin and norfloxacin). Indeed. pneumoniae isolates 1A4. indicating the emergence of this resistance mechanism in the Palestinian hospitals. can easily spread from one bacteria to another in the hospital setting (41. while the presence of carbapenemase enzymes was confirmed by the modified Hodge test. all isolates were resistant to all β–lactam antibiotics. tigecycline. co-trimoxazole. © Under License of Creative Commons Attribution 3. and nitrofurantoin which further complicate patient’s infection management. On the other hand. Consistent with earlier reports that blaKPC positive Enterobacteriaceae are usually multidrug resistant organisms. 2 No. Of the 31 different β–lactamase genes investigated. where histidine was replaced by tyrosine (H272Y) (35). blaTEM and blaSHV have been previously reported from several countries (35. In Palestine. 1A2 and 1A3. High carbapenems (ertapenem. blaGES-23 and blaKPC-2) genes is the Palestinian bacterial isolates is alarming and mandates the Palestinian Ministry of Health (Pal-MOH) to take practical steps in order to help the Palestinian hospitals in detecting these extremely drug resistant pathogens. The extremely drug resistance profile that the Palestinian blaKPC-2 isolates exhibited was further investigated by screening the bacterial cell lysates for the presence of different β– lactamase genes by PCR. Sequence analysis of the four Palestinian bacterial blaKPC genes revealed that they all belong to blaKPC-2 type. Thus. 17. Indeed.0 License 7 . Variable sensitivity patterns were noted for the fluoroquinolones (ofloxacin.3823/713 Our Site: http://www. ESBL’s and blaAmpC. 1A3 and the K. thus leaving the health care providers with limited options for how to treat patients infected with blaKPC positive bacteria (Table 2). while the blaAmpC (blaMIR-1) was detected in all E. pneumoniae isolates carrying the β–lactamase genes. 2:4 doi: 10. The presence of the blaGES-23 enzyme which might have some carbapenemase activity with the blaKPC-2 is a strong reminder about the seriousness of this emerging problem. the first report of the presence of both blaKPC and blaGES genes in a member of the Enterobacteriaceae family. Eleven different types of blaKPC genes have been reported in different bacterial genuses worldwide. cloacae and K. the co-production of blaKPC and blaGES has been previously reported in an Aeromonas spp. imipenem and meropenem) with MIC’s (>32mg/ mL) confirmed the disk diffusion results. The presence of these resistance mechanisms in combination with the blaKPC is extremely rare and at the same time alarming as these plasmids encoded β-lactamase genes. all isolates reported here showed multidrug resistance profile (12. the blaOXA-1 was detected in the E. and gentamicin. 29). the Pal-MOH must take action in controlling the misuse of antibiotics and must mandate activation and monitoring of the Palestinian hospitals infection control programs in order to prevent the spread of these extremely drug resistant bacteria.com/ with no prior travel history outside occupied Palestine. 38-40). Several E.imedpub. cloacae and K. blaMIR-1. cloacae isolates. blaOXA-1. This is of extreme importance since it represents. The presence of all these plasmids encoded β–lactamase (blaTEM. cloacae isolates 1A1. cephamycins and monobactams (43). blaSHV. since they have activities against carbapenems. The blaGES enzymes possess an unusual phenotypic plasticity. 42). the presence of these resistance mechanisms does not preclude the presence of other rapidly spreading carbapenemases in the Enterobacteriaceae family such as the recently reported blaOXA-48 in Lebanon (45). extendedspectrum β-lactams. 10. What was more disturbing was the detection of the plasmid encoded blaGES gene in the three E.iMedPub Journals 2012 THE INTERNATIONAL ARABIC JOURNAL OF ANTIMICROBIAL AGENTS Vol. all isolated lysates contained the blaTEM and blaSHV genes.

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